MSkel III Cervical Spine

much should the A-O joint distract

-if alar ligaments are intact 1-2 mm

sicard sign

-if the SLR is +, come out the painful range and rapidly increase great toe extension - (+) = sicard sign = pain returns = indicates lumbar radiculopathy

neural elements of the spine

There are eight pairs of cervical nerves, although there are only seven cervical vertebrae C1 exits above C1 vertebrae and so on down to C7 where there is an additional nerve that exits below the C7 vertebrae, C8 spinal nerve

evidence for mckenzie approach

There is moderate evidence that supports that the disc does not move in a specific direction or behave in a specific manner with repeated movements or specific postural positioning

evidence for posture

There is moderate evidence to support that postural asymmetry is not directly correlated to a specific impairment

diagnosing cervical radiculopathy

ULTT A (upper limb tension test)—median and radial nerve tension tests Ipsilateral rotation is <60 degrees Distraction Test—performed in supine or standing, manual traction is applied to the head. A positive test occurs with reduction or elimination of symptoms Spurling Test—a patient's head is passively sidebent to the symptomatic side and overpressed. The test is positive if there is symptom reproduction. -if you have 4/4 of the above criteria = 90% sure radiculopathy ( 2 positive tests—21% 3 positive tests—65% 4 positive tests—90% )

when should UQS be performed

- There is no history of trauma - There are radicular signs - There is trauma with radicular signs - There is altered sensation in the limb - There are signs of a spinal cord injury - There are abnormal patterns or you suspect psychogenic pain

what to do if a comparable sign cannot be elicited with basic movements

-graduation of forces used -like: overpressure, repeated movements, sustained pressure, combined movements, combined movements that are repeated or with sustained pressure

cervical spine has a greater and lower incidence of what when compared to the lumbar spine

-greater: spondylosis -lower: herniated disc

how do you approach seeing which movement reduce pain

-have pt move through a series of activities and test movements to gauge the pt's pain response -the approach then uses that info to develop an exercise program designed to centralize or alleviate the pain

headache tx

headache snag, reverse headache snag, Maitland oscillations -exercise is one of the best things you can do

self SNAG for rotation

hold towel with a pincer grip, take the long edge and find segment -let go and grab the opposite corners -pulldown with one, eyes are looking at the one that is straight ahead, turn away (back of hand is moving out/laterally)

the majority of nontraumatic neck pain has a ____

strong postural component

sx muscle tension headache

suboccipital area is tightened up, pain wraps up on the back side of the head

what test can be performed to test the ANS

sympathetic slump test

what is the single best test for acute radiculopathy

the ULTT—a negative ULTT significantly reduces the diagnosis of radiculopathy (Sensitivity is approximately 97%)

what are degenerative changes noted by

the loss of intervertebral disc height and osteophyte development

The examination is made up of two major components

the subjective examination (SE) and the physical examination (PE)

when do sx for discogenic problems start

the symptoms commonly start spontaneously, even if the herniated disc originates from trauma or injury

what do tx techniques depend on?

the type of disorder

how is empowering the pt in the performance and follow through of the exercise program achieved

through assisting the patient in observing and appreciating changes in the patient's symptomology

The primary goal of orthopedic exam is

to diagnose movement dysfunction

why are manipulation techniques used

to reduce small cartilaginous displaced fragments both in the spine and in peripheral joints (loose bodies) -restore normal mobility in a joint restricted by ligamentous adhesion and in subluxation of bones

what are sites of injury based on?

vulnerable anatomic sites where an initial injury is most likely to occur

what are the hallmarks of neuro signs

weak and painless, gait impairment, clumsiness, bowel and bladder, lack of fine motor skill

joint sign

A joint sign isan abnormal joint movement that may be seen or felt • If it is felt it could emanate as stiffness or spasm

examining movements

Active movements (Tests all anatomical structures and the patient's willingness to move) Passive Movements (End feel, joint integrity, stage of recovery) Resisted Movement (Principal screening for contractile elements— determines the need for more precise strength testing, i.e. MMT) Palpation (pathological state of the tissue, temperature, trophic changes, etc) Neurological Testing (reflexes, sensation, etc.) Special Tests—tests that intended to quickly determine the presence of a condition

what are the three main causes of headaches (from cervical spondylosis)

C1-C2 vertebrae Entrapment neuropathy of the occipital nerves—the greater occipital nerve runs through the semispinalis capitis and upper trapezius from the midline. -- Irritation or compression can cause a burning, throbbing pain from the neck into the posterior head Musculotendinous lesions of the attachments of the cervical muscles to the nuchal line of which there are three causes: Posture—forward head, Chronic tension, Tendonitis

where does the greatest reduction in rotation, lateral flexion and flexion/extension occur

C6-7 and T1-2.... C-T junction (where the lordotic curve transitions to a kyphotic curve) -resulting in significant stress

types of headaches

Cervical Headache Muscle Tension Headache Migraine Headache with aura Migraine Headache without aura Cluster Headache TMJ Headache • Remember—a headache may come from more than one source

outcome measures

Clinicians should use validated self-report questionnaires, such as the Neck Disability Index for patients with neck pain These tools are useful for identifying a patient's baseline status relative to pain, function, and disability and for monitoring a change in a patient's status throughout the course of treatment

previous hx questions for headaches

Date of onset Predisposing factors, injuries Progress since onset Previous treatment including drugs, injections, surgery, manipulation, etc. Frequency and duration of recurrences

migraine without aura makes up how much of all headaches

Estimated to comprise approximately 25% of headaches

special questions

General health Surgery Medications Imagery Cough/sneeze, Bilateral pins and needles, saddle paresthesia, gait disturbance, bladder dysfunction, etc. • Red Flags? Yellow Flags (psychological or behavioral factors) Diagnosis Impact on the patient

Five "examination questions" are addressed that provide essential Evaluation information:

Is this a musculoskeletal problem? (Relates to "Screening" and "Differential Diagnosis") What are the regions involved? (dermatomes, peripheral presentation?) Are the involved structures contractile or non-contractile? (cyriax) What are the correct structures involved and the location of involvement on the structure? (maitland) What is the nature and extent of the problem? (radiate or refer)

neurodynamics summary

It is clinically practical to perform each assessment and re-assessment on a given patient in a specific order If the test is performed differently each time it is applied, an order may alter the results of the examination, misleading the therapist in determining if a clinical change is present Likewise, sensitizing maneuvers should be performed in a consistent manner to enhance reliability Consistent positioning should also be considered when applying a specific examination for neural tissue As a whole, the tests are reliable for clinical use

presentation of cervical spondylosis

Neck Pain • Dull ache or diffuse pain in the neck and interscapular region or shoulder which increases to pain with activity and quick movements and it is usually worse in the morning • Arm pain (usually in extensor aspect) is either referred pain or due to nerve root pressure—commonly the C6 and C7 nerve roots Headaches that are present are most likely associated with the O-A and A-A joints, tendonous lesions at the nuchal line, and/or nerve root or nerve root sleeve irritation or fibrosis Neck movements reproduce or increase symptoms Accessory test movements are more helpful than the physiological tests May be two levels involved on opposite sides of the neck

migraine with aura

One or more "passegerefocal neurological symptoms" (PFNS), i.e. aura—from the brain --prodronal sx The PFNS gradually over >4 minutes, or two or more PFNS follow each other None of the PFNS lasts longer than 60 minutes Headache typically starts within 60 minutes after onset of PFNS (but may start earlier)

sx of nerve root compression

Pain in a dermatomal pattern Myotomal weakness Reflex changes (diminished on the same side)

physical exam for headaches

Posture—especially of the head, neck and shoulder Examine the cervical spine for symptom production or dysfunctions that may suggest mechanical disturbances and tissue irritability • Active movements—looking for both quality and quantity of movement, overpressure is applied as appropriate • Passive movements • Resistive movements—especially deep neck flexor strength Examine the TMJ and muscles of mastication for pain and tenderness, clicking and movement abnormalities Vertebral artery (VBI) and instability testing as needed Soft tissue palpation, trigger points, muscle length tests (especially in the suboccipital area) Neural tension and dural testing using ULTT, slump and neck flexion

referred pain vs radicular pain

Referred pain is more diffuse -radicular pain is more specifically along the course of a dermatome

self SNAG for headaches

Selvage of towel just under the occiput pulling forward and retracting the neck

red flags

Significant trauma Weight loss History of cancer Fever Intravenous drug use Steroid use Patient over 50 years Severe, unremitting night-time pain Pain that gets worse when lying down

spurlings

The Spurling's maneuver appears to be specific but not sensitive and would not function well as a screen, according to Cook SB

posture

The majority of non-traumatic neck pain has a strong postural component Static loading with poor sitting or lying postures eventually lead to problems within the cervical spine • Poor posture also can enhance or perpetuate an already existing cervical pain from trauma It is necessary to assess posture in sitting, standing, sleeping, leisure, recreation and work postures

causes of discogenic problems

(posture, injury early in life, genetic issue)

foam roll and posture

(vertical: stretch pecs, foraminal and facet motion) or horizontal and roll on it back and forth to get some self mobilization

four parts to the UQS

- AROM of the Extremities: AROM testing is part of the screening exam to rule out any obvious pathology -Myotomes: tested to check the integrity of the nerve root -Sensation:Sensation testing is performed to rule out neurological problems -Reflexes: Hyperreflexiaor an increased muscle contraction (graded 3 or 4) is a sign of an upper motor neuron problem while a normal reflex is graded as a 2 or 2+

SNAG for flexion

- Done in a weightbearing functional posture. The mobilization is sustained through the movement of flexion/extension, side bending, or rotation - The movement is always painfree—if it is not painfree you are on the wrong segment or you are mobilizing in the wrong plane - 3 sets of 10 or 4 sets of 8

SNAG for SB

- Done in a weightbearing functional posture. The mobilization is sustained through the movement of flexion/extension, side bending, or rotation - The movement is always painfree—if it is not painfree you are on the wrong segment or you are mobilizing in the wrong plane - 3 sets of 10 or 4 sets of 8 -central mob, pt applies overpressure

SNAG for cervical rotation

- Done in a weightbearing functional posture. The mobilization is sustained through the movement of flexion/extension, side bending, or rotation - The movement is always painfree—if it is not painfree you are on the wrong segment or you are mobilizing in the wrong plane - 3 sets of 10 or 4 sets of 8 on articular pillar (over the prcess where the facet lies) laminar gutter -pt adds over pressure through chin

SNAG for flex/ext

- Done in a weightbearing functional posture. The mobilization is sustained through the movement of flexion/extension, side bending, or rotation The movement is always pain free—if it is not pain free you are on the wrong segment or you are mobilizing in the wrong plane -3 sets of 10 or 4 sets of 8 central snag -medial border of thumb, place it on the spinous process, take mobilizing thumb and create a 90 degree angle -glide and hold, then do movement -have pt go into flexion, PT moves with them to maintain mob all the way through the motion -at end range, ask pt to take their hand and apply overpressure -tx for facet, flexion, disc (do to opposite side to open up space for disc) dysfuntion, arthritis -can repeat with extension NO OVERPRESSURE (weight of head is enough)

behavior of sx for each sx area

- Establish the symptom behavior over a 24 hour period • Morning, throughout the day, end of the day, night pain/sleeping pain, and work day versus non-work day -Activities that make the symptoms better/worse, increase/decrease, produces/eliminates • Indicate the time it takes to settle or eliminate the symptoms

C2-7

- Facets are in a plane of 45 degrees between the frontal and horizontal planes—this allows significant movement in all three planes -20—25% of total cervical flexion takes place at the O-A and A-A joints -C5—C6 has the greatest range of flexion and extension and is most prone to degeneration—it is also the pivot point for lateral flexion

evidence for the cyriax approach

- Fair evidence that the theory of selective tissue tension is not applicable to all conditions - Conflicting evidence that capsular pattern theory demonstrates validity and findings depend substantially on how patients are selected for assessment - Some evidence refutes the reliability of Cyriax's end-feel classification

self SNAG - flex/ext

- For lower cervical dysfunction, utilize the selvage of a towel on the spinous process of the selected segment and provide a pull through the plane of the eyes and move into extension or side bending if pt is benefiting from SNAGS and you want to give them a HEP -take the long edge of the towel, hold the two corners, wrap around shoulders: find segment you want to mobilize -arms stay in, anteriorly translate, eyes stay on thumb and index fingers: as you extend neck, hands go with eyes: maintaining the translatory glide with extension

five exam questions that provide eval info

- Is this a musculoskeletal problem? (Relates to "Screening" and "Differential Diagnosis") - What are the regions involved? - Are the involved structures contractile or non-contractile? (cyriax) - What are the correct structures involved and the location of involvement on the structure? (maitland) - What is the nature and extent of the problem?

reverse NAGs

- Make a "V" with your thumb and forefinger and pronate and ulnarly deviate your wrist - Apply your oscillations through the plane of the spinous process towards the eyes -mostly used for lower cervical spine C6-7, maybe T1 -moving inferior on superior -usually do this in the acute stage where they are afraid to move head -biceps on forehead: hook with middle phalanx (keep head in neutral) -find spinous process with "V" of other hand, glide up towards eye -other hand is stabilizing segment above for larger joints C4-C7/T1, more for fibrotic joints

NAGs

- NAGs are oscillatory— approximately 3x's per second -Use the middle phalanx of the little finger against the spinous process you are mobilizing and reinforce the movement with the thumb of your other hand -no grades, oblique plane, pain free mobs support middle phalanx of the pinky and stabilize the joint below with the thumb and glide up towards the eye -stride step, biceps on forehead 3x/second- too quick use staccato movement -other hand between shoulder blades.. this hand is the hand that mobilizes (thumb pushes pinky)

maitland upper cervical oscillations A-O

- Oscillations on Occiput/C1 directed towards the ipsilateral eye - Joint is deep under the suboccipital musculature - GI and GII oscillations for 30 to 45 seconds

unilateral P-A PAIVM

- Palpate through the musculature - Start over the articular pillars - Direct your force at the articular pillar or the laminar gutter

evidence for kaltenborn

- There is strong evidence to support that the convex-concave rule does not apply to the glenohumeral joint—there is some evidence that the rule is effective for the ankle and knee - There is strong evidence that suggests that approaches that over utilize special tests will harbor inappropriate diagnoses and findings

fist traction HEP

- This is a follow-up for a SNAG of the cervical spine for a loss of cervical flexion - Hold 10 seconds x 3 for flexion SNAG -make a fist, hypothenar eminence is on jugular notch -drop chin right on the fist: forcibly flex down, add overpressure with other hand -similar to a hold relax or contract relax

transverse PAIVM

- Use the Dummy Thumb - Provides a rotational component to the segment - Often used to centralize symptoms usually pushing toward the side of pain

central P-A PAIVM

- Use the pads of the thumbs—you can decrease the area of the thumbs to isolate and specify the area - Tips of the thumbs can be used between the segments of C4 to C6

headache SNAG

- \Stand astride your patient -Use the middle phalanx of the little finger against C2 -Glide in straight A-P plane and hold for 10 seconds -This is a sustained mobilization—Repeat 6-10x's forehead into bicep, C2 spinous process (open hands) -glide head anteriorly, sustain,

what do the PLL and tectorial membrane limit

-flexion, rotation, distraction of the head on C1-C2

SLR modifications

-2: hip is flexed, knee extended, ankle DF, foot everted, toes extended (tests the tibial nerve exclusively) -3: hip flexed, knee extended, ankle DF, foot inverted (tests the sural nerve exclusively) -4: hip flexed and IR, knee extended, ankle PF, foot inverted (tests the common peroneal nerve exclusively) -5: crossed leg test: hip flexed, knee extended, ankle DF, uninvolved leg is elevated to 70 degrees (this helps confirm a nerve root problem by placing tension on the uninvolved side which in turn will place tension on the involved side)... adding neck flexion to a SLR as a sensitizing maneuver and getting a positive response = brudzinski sign

A-A joint

-50% of cervical rotation takes place here Three joints: • 1 median joint formed by the dens of C2 and the anterior arch of the atlas—held by the transverse ligament • 2 lateral joints—the joint surfaces are nearly flat to allow significant rotation

when does sciatic nerve movement take place with SLR

-A SLR will draw the sciatic nerve downward through the greater sciatic notch (area of tension) pressing it against bony structures. • From 0 to 30 degrees movement of the nerve within the notch has already begun • From 35 degrees to 70 degrees the nerve root begins to move • From 70 degrees to 90 degrees the nerve root no longer moves but tension is increased

A-O, A-A, C2-3 mobility assessment

-A-O: 8 fingers, ring finger then apply translation towards eye -C2-3: articular pillar P-A glide -A-A: 20-30 degree ipsi rotation (towards palpating finger), glide towards mouth • The test is both a test for pain provocation and hypomobility • Test shows high specificity, but some of the subjects were asymptomatic, which can amplify diagnostic accuracy

B-UI-A-T-C

-B: where nerve branches -UI: unyielding interface -A: attachment -T: tunnel (cubital in radial nerve ex) -C: where the nerve becomes cutaneous/superficial

critical thinking - maitland

-Be flexible—not dogmatic -Emphasize metacognition— thinking about your situation with the patient •Important in high level clinical reasoning •Emphasizes lateral thinking •Maitland's "Permeable Brick Wall" •Create an hypothesis and settle on a diagnosis (Accept, reject or modify the hypothesis as you go move though your visits)

McKenzie is the only concept that does what?

-fully emphasizes specific home exercises and independent patient management and education

compression

-Both hands on the vertex of the head and apply gentle compression -Vary the angles of flexion, extension, and lateral flexion -Reproduction of symptoms is considered a positive response -Used as an assessment tool—the kappa value suggests the test has only fair agreement, according to Bertilsonet al.

prevention - mckenzie

-By learning how to self-treat the current problem, patients gain hands-on knowledge on how to minimize the risk of recurrence and to rapidly deal with recurrence if it occurs -The likelihood of problems persisting can more likely be prevented through self-maintenance -Extension in Lying is the primary focus in treating the spine

facet joints

-synovial, planar, diarthrodial joints that are oriented in an oblique plane

CROCKS

-Contraindications—bone quality, joint structure (unstable), blood vessel patency, and skin integrity (frail skin) -Repetitions: 6—10 repetitions for 3—5 sets (a first session would more likely to be 3 repetitions for 1 set) -Overpressure: maximal passive range is achieved by therapist applied overpressure at the end of the joints active range -Communication/Cooperation: practitioners must inform patients of expected effects and patients must communicate with practitioners the presence of discomfort or pain -Knowledge: practitioners must have knowledge of musculoskeletal medicine, pathology, biomechanics and anatomy -Sustain/Skill/Sense/Subtle: ensure that the glide is held for the entire duration of the movement (sustain), the more practice the better the technique (skill), through practice the therapist gains a greater sense of feeling in their hands (sense), movements are very minute (subtle)

A-O joint

-Convex occipital condyles that articulate with the concave superior articular facets of the atlas -- 60 degrees in an oblique plane towards the eye • It is the only cervical segment with this convex—concave relationship (All other cervical facets are planar) • Anteriorly the capsule of each A-O joint blends with the anterior A-O membrane and the anterior longitudinal ligament -most flexion and extension occurs here

uncinate joints

-Described by von Luschka -Formed by the uncovertebral process—a raised lip on the superior-lateral surface of the vertebral bodies • Develop by the age of 6—10 -The concave superior surface of the vertebra receives the vertebral body above and articulates with it to form the uncovertebral joint • Limits side bending and guides (sagittal plane movement) flexion and extension -increases stability in frontal plane

Maitland C2-3 oscillations

-Force on the C2 articular pillar of C2 without any rotation will affect the C2 on C3 segment - Thisis a regular unilateral P—A mobilization on C2 - Neutral position of the head affects C2 -GI—GII oscillations on the articular pillar x 30 to 45 seconds

key components to assessment - maitland

-Irritability: if the activity causes pain (can be delayed).. if pain goes away in a few hours, not too irritable -Comparable sign: what pt complains of -Differential diagnosis -Relationship between pain and stiffness

average sciatic nerve movement with SLR

-L4 1.5mm (< 1/16) -L5 3.0mm -S1 4.0mm Can work at L4 to help increase movement for the rest of the tunnel

should you tx the affected or the unaffected side first?

-unaffected: see how it reacts, get a baseline -protects the involved side from increasing irritability

maitland summary

-Maitland's mode of thinking is probably the most important part of the concept • Emphasizes assessment and continuous hypothesis testing • Emphasizes reassessment of the comparable sign to help guide the clinician

mckenzie tx

-McKenzie treatment prescribes a series of individualized exercises -The emphasis is on active patient involvement, which minimizes the number of visits to the clinic • Ultimately, most patients can successfully treat themselves when provided the necessary knowledge and tools -after completely centralizing, go into a flexion posture then end with extension

ULTT test 1- median nerve bias

-Patient is supine and the therapist faces their head with one hand lightly stabilizing the shoulder -Abduct the arm to approximately 110 degrees—the elbow is held in 90 degrees of flexion and the hand is kept in neutral -Add wrist and finger extension -Add forearm supination -Add elbow extension and monitor the symptoms • Sensitize with lateral neck flexion away and towards

ULTT 3 - ulnar nerve bias

-Patient lies supine and the therapist stands facing their head with one hand lightly stabilizing the patient's shoulder -Extend the wrist and pronate the forearm -The elbow is flexed to 90 degrees -Depress the shoulder girdle -Laterally rotate the shoulder -Abduct the shoulder • Sensitize with cervical lateral flexion towards and away

alar ligament stability

-SB 10 degrees -rotation 20-30 degrees feel spinous process of C2 - + = failure to feel movement of the C2 process during SB or rotation

reverse headache SNAG

-Stand astride your patient -Your upper hand is on the occiput and the web space of your lower hand is over C2 -Position the occiput slightly forward and apply pressure downward with the lower hand on C2—this is a sustained mobilization pt retracts, relaxes, -PT holds position here, has webspace over C3 and anteriorly translates -straight forward -hotpack, then manual therapy, or ice to reduce nerve conduction velocity before MT -retract each time... hold 10 seconds 6-10x

maitland concept

-The Maitland Concept of Manipulative Physiotherapy emphasizes a specific way of thinking, continuous evaluation and assessment and the art of manipulative physiotherapy and a total commitment to the patient (patient centeredness) -big on clinical decision making/thought process, and analytics of the interview then exam confirms, rejects, or modifies hypothesis -also big on manual therapy

ULTT 2B - radial nerve bias

-The patient lies supine and diagonally on the plinth with their shoulder close to the edge—the therapist stands facing the patient's feet -Grasp the patient's arm so you can fully medially rotate their arm -Add shoulder girdle depression with your knee— the arm is kept in 10—20 degrees of abduction -Add elbow extension -Add whole arm internal rotation and pronate the forearm -Add wrist flexion and ulnar deviation • Sensitize with cervical flexion towards and away

ULTT test 2A - median nerve bias

-The patient lies supine and diagonally on the plinth with their shoulder close to the edge—the therapist stands facing the patient's feet -Your thigh rests lightly against the patient's shoulder -Hold the patient's hand with one hand while the other hand cradles their arm which is held in elbow flexion -Add shoulder girdle depression -Add elbow extension -Add whole arm lateral rotation -Add wrist and finger extension • Sensitize with lateral flexion towards and away

patient centered approach - maitland concept

-This key component is based around a personal commitment to the patient -We, as clinicians, need to consider the patient's perspective •Communication is very important in getting the necessary information from the patient

tx for cervical spondylosis

-Traction: manual or mechanical (if manual doesn't work, the other may not work) -mobilization for movement 3-4 (only for pain if it is acute), P-A -massage to loosen up the muscles -AROM in all direction, stretch, stabilize (resistance work) -postural education -ergonomics (put them in a better position for work/activities) -modalities: heat, e-stim (with heat or ice), deep heat, TENS

tx techniques of maitland

-Treatment techniques grow out of the subjective and physical examination • Think of stretching stiff tissue with the intent of producing the pain of a stiff— dominant disorder thus increasing range • Think of only gently moving painful tissue with the intent of reducing and eliminating the pain of a pain-‐dominant disorder

sensitizing maneuvers

-Used during the neural tissue provocation tests which allow clinicians to differentiate between neural tension and other non-neural or musculoskeletal pathologies • Sensitizing maneuvers involve applying additional tension in the nervous system without directly involving the local segment in question • Perform the maneuvers in a systematic manner in order to keep your data organized -can sensitize and desensitize by adding/removing a proximal stretch (at neck)

cervical side glide

-Useful to test and mobilize neural elements in the cervical spine -Possibly moves the foramen around the nerve root -Position the head in mid flexion/extension -Grasp the neck with one hand and the other hand may overlap to help with support -Therapist shifts their weight from side to side and glide the head side to side avoiding side flexion -Glide the neck and head to the right or left • Progress by adding elbow extension, or ULTT 2a or 2b

neurodynamics

-a concept that involves the dynamic interplay between the physiological properties of the peripheral nervous system -this concept assumes that these properties are interdependent and when altered can effect the peripheral and CNS in a clinically oriented manner through observable and pt reported signs and sx -nervous tissue is continuous (from head to toe)

what age is there no longer any nucleus pulposus left

-age 45 -herniated discs are rare

comparable sign - maitland

-aka holy grail of the concept -A comparable joint or neural sign refers to a combination of pain, stiffness and/or spasm which the examiner finds on examination and considers it to be comparable with the patients symptoms • The sign must reproduce the patient's symptoms or cause abnormal pain in the absence of the patient's symptoms

neurodynamic testing: prone knee bend

-assesses femoral nerve

neurodynamic testing: SLR

-assesses the sciatic nerve and tibial nerve, LBP -hip flexion, knee extension, DF -can bias other nerves by adding eversion, DF, inversion (can differentiate other nerves) -Bragard sign, lesague test, sicard sign

what is the goal of mckenzie method

-centralize pain -educate pt

mckenzie assessment & red flags

-consists of taking a patient history and performing a physical exam • Both are used to gauge the degree of impairment as well as identify any red flags that might be contrary to exercise based treatment (e.g. fracture, tumor, infections, or systemic inflammatory disease) -During the physical examination, patients are taken through certain movements that help classify the patient and determine the best treatment approach -These movements are intended to either increase or decrease symptoms • For example, patients may be asked to perform single and/or repeated flexion or extension movements to provoke or reduce the painful symptoms

what is provisional dx synonymous to

-creating a clinical hypothesis (accept, reject, or modify)

causes of spondylosis

-degenerative changes in the disc, vertebra, and facet joints This leads to osteophytic outgrowths into the intervertebral foramen This is more common and is more severe than in the lumbar spine

diff dx for radiated pain down mid scapular area

-discogenic problem -may also be dural tension (blurmette sign) which goes down both sides of the spine like an electric shock

difference between cervicogenic and vestibular dizziness

-vestibular: (room) spinning type of dizziness -cervicogenic: wooziness (you are spinning)

dysfunction syndrome

-implies some sort of adaptive shortening, scarring or adherence of connective tissue causing discomfort (a previous injury may be detected in the history) -A dysfunction may be intermittent or chronic, but its hallmark is a consistent movement loss and pain at the end range of movement -When the patient moves away from end range their pain is decreased

why are active movements and proprioceptive training used

-in the treatment of functional disorders and instability -In the treatment of minor muscular tears they are very useful in avoiding the formation of abnormal intra-lesional adhesion formation

why is deep friction used

-in treating traumatic and overuse soft tissue lesions -The rationale for using deep friction (which is in fact a form of soft tissue mobilization) is supported by experimental studies of the past several decades that confirm and explain the beneficial effects of the activity on the healing of musculoskeletal tissues

what is important with pt education

-it is imperative that the patient understand the role that the nervous system plays in his or her pathology, the concept of neural mechanics, and they all interact to alter movement and function

lesague test

-le-say-gue -sensitization: if SLR is positive, come out of the painful range and rapidly increase DF - (+) = bragard sign: pain returns = indicates sciatic neuritis

what does PT education for thrust manip emphasize

-movement science and analysis -Expertise is grounded in anatomy, physiology, biomechanics, and pathology -Provides foundation for determining clinical decision making needed for thrust-joint-manipulation • Students receive psychomotor training and testing required for safe thrust-joint-manipulation

cloward sign

-pain, usually on one side, referred into the midscapular area -can exist without the radiation of arm pain

slump test

-performed with the subject sitting on the edge of a table of adequate height so that the feet are off the floor and the therapist can easily reach the subject's leg while standing -The test is performed in a functional position that commonly reproduces an individual's low back and leg pain and is often credited to Geoffrey Maitland -assesses sciatic nerve

tx for acute radiculopathy

-pt education: posture -traction -mobilize the tension point (where the pain/sensitive points were) -stabilization/strengthening esp for anterior deep neck flexors (rectus capiti, longus colli)

positions for VBI

-repeat with rotation, extension, SB

disc herniation presentation

-similar to those of the lumbar spine—pain radiating down the arm is typical of an acute disc herniation in the C-spine Pain may also refer into the mid-scapular area (Cloward Sign)

neurodynamic testing: slump test series

-sitting: sciatic -sidelying: femoral nerve

common sites of injury

-soft tissues, osseous, or fibro-osseous tunnels (the median nerve in the carpal tunnel or a spinal nerve in the intervertebral foramen -where the nervous system branches (plexus): this is particularly true when a branch leaves the main trunk of a nerve at an abrupt angle... when a nerve branches, it sacrifices some of its gliding mechanisms and hence may become susceptible to injury -where the nervous system is fixed -areas where the nervous system may be exposed to friction forces as it passes in close proximity to unyielding interfaces -tension points

tectorial membrane test

-stabilize C2 and distract head -should only distract 1-2 mm

uses for A-O joint palpation

-suboccipital headaches, cervicogenic headaches, stiff upper cervical flexion and extension

neurodynamic testing: passive neck flexion

-tests the dural tube or can be used to sensitize other neurodynamic tests (both sitting and supine) -sitting and supine have different names (supine - kernig sign) -movements can be active or passive - (+) = Lhermitte's sign = sharp, electric shock that runs down the spine and into the upper or lower extremities

prone knee bend

-tests the femoral nerve • The subject is lying prone on a plinth and is questioned regarding his or her current symptom level • The therapist applies knee flexion and hip extension to end range or until a comparable sign is provoked -This is a very good test to screen for mid lumbar (L2, L3, L4) nerve root impingements -Sensitization can be applied using cervical flexion or extension or cervical side bending

sharp-purser

-tests transverse ligament which prevents anterior displacement of the atlas on the dens -stabilize C2, feel for excessive movement or clunk of relocation of dens

ex of where the nervous system is fixed

-the common peroneal nerve at the head of the fibula -dura mater at L4 vertebral segment -attachment of the radial nerve to the radial head -the suprascapular nerve in the scapular notch

ex of areas where the nervous system may be exposed to friction forces as it passes in close proximity to unyielding interfaces

-the cords of the brachial plexus passing over the first rib -the radial nerve in the groove of the humerus -the dural sleeves running close to the pedicles

derangement syndrome

-the most common syndrome of the three (some type of disc related pathology) -This is an example of back pain that is caused by a change in position of the vertebrae enclosing a disc due to repositioning of the fluid nucleus of the disc • In a case like this the pain will change with repeated motions such as a flexion or extension and the symptoms will either become more central or more peripheral

what are people also mobilizing with manual therapy

-the nervous system

gliding techniques

-the patient is placed in a position of comfort but appropriate to provide neurodynamic load -The neural tissue in question is loaded by applying movement and strain through one end of the nerve while strain is relieved from the other end of the nerve at the region to be treated

tension techniques

-the patient is placed in a position of comfort but appropriate to provide neurodynamic load -The neural tissue in question is loaded by applying movement and strain through the nerve on either side of the region to be treated -The load is repetitively applied in an oscillatory fashion

stretching techniques

-the patient is placed in an appropriate position to neurodynamically load the tissue -Strain is applied to the system and is sustained for a pre-determined amount of time • Segmental Mobilization Techniques—the patient is placed in an appropriate position to apply a pre-determined amount of neurodynamic load; the therapist applies an oscillatory technique to an appropriate segmental level to move the segment around the nerve

postural syndrome

-the result of prolonged positions or postures that can affect muscles, tendons, or joint surfaces -Pain may be local and reproducible when end range positions, such as slouching, are maintained for sustained periods of time

passive upper cervical extension quadrant (combo)

-three components: extension, ipsi SB, ipsi rotation •One hand is placed on the head and the other on the chin -Patient actively pokes the chin to extend his upper cervical spine, then you passively extend to end of range • Hold Extension -Add sidebending of upper C-spine toward you • Hold both movements -Add rotation of the upper C-spine toward you

why are injection and infiltration techniques used

-to reduce traumatic or rheumatoid inflammation -They are most valuable in arthritis, bursitis, ligamentous and tendinous lesions and in neuro-compression syndromes

why are gentle passive mobs used

-to stretch capsular adhesions and to improve the function of ligaments and tendons -In the treatment of traumatic injuries they are often used in combination with deep transverse massage.

discogenic problems tx

-traction; elongate and allow disc to move back into place -mobilize neck (segments that are not painful) and thrust manip thoracic spine) -correct posture -pt education: avoid flexion, promote extension (towel roll under neck) -cervical strengthening and stability exercises (esp in extension)

what is mechanical pain

-when a joint does not move properly: same pain happens with the same movement

what creates tension points

-when nervous tissue moves in a different direction than the moving body parts have

summary of the cyriax method

1. Examine the AROM, PROM, and the isometric muscle testing (basis of selective tissue tension testing) 2. At the end of testing PROM determine what the end feel is within the joint 3. If the PROM is limited, determine if the limitation is capsular or non-capsular 4. Identify a treatment technique that is dependent on the type of disorder

The symptoms evoked on a neurodynamictest can be can be inferred to neurogenic if:

1. Symptoms can be reproduced 2. If responses on the involved side differ from the uninvolved sideor from known normal responses 3. If structural differentiation supports aneurogenic source 4. If there is support from other data such as history, imaging tests, area of the symptoms, etc.

what age is common for dicogenic problems

30-50 (disc get smaller after age 45 so it is unusual after 45)

how many joints are in the c-spine

37 joints

weight of the head

8 lbs -forward head = +10 lbs per 1 in?

tx for headache

According to the clinical practice guidelines linked to the international classification of functioning, disability, and health from the orthopedic section of the American Physical Therapy Association for neck pain Cervical Mobilization/Manipulation Thoracic Mobilization/Manipulation Stretching Exercises Coordination, Strengthening, and Endurance Exercises Centralization Procedures and Exercises Upper Quarter and Nerve Mobilization Procedures Traction Patient Education and Counseling

muscle tension headaches are characterized by

At least two of the following characteristics: • Pressing/squeezing/dull aching, non-throbbing • Mild to moderately severe • Bilateral • No increase in pain with simple ADLs No vomiting or severe nausea No more than one of the following symptoms • Photophobia • Phonophobia

bony palpations

Feel for abnormal tissue changes and positions including spinous processes, the interlaminar spaces, the articular pillars, and the T4 area and the angle of the ribs

indications for NAGs

Indications are for the elderly, the acute wry neck, and for multi-directional instability is oscillatory to promote movement

osseous structures palpation

Inion, mastoids, angle of the jaw, spinous processes of C2— C7, transverse processes of C1, the articular pillars

present illness questions for headache

Location of symptoms Intensity of symptoms Character and quality of the headache Constant versus intermittent Duration and frequency of the episodes Aggravating and easing factors Variations with time of day Night pain and effect on sleep Medications and their effect on sleep

thrust malpractice

Maginnis and Associates liability Insurance carrier has provided a letter to APTA stating that there is no evidence of higher claims losses due to physical therapy students utilizing manipulative procedures • "It is critical that therapists are able to read and interpret x-rays, MRI's, and CT scans in order to make a proper diagnosis that would be indicative of a manipulation, as well as contraindications of a manipulation"

Agency for Health Care Policy and Research (AHCPR, '94) says...

Manipulation can be helpful for patients with acute low back problems without radiculopathy when used within the first month of symptoms. (Strength of Evidence = B) First major clinical guideline to recommend TJM (thrust joint manip) for LBP

movement testing

Move to and slightly into the pain • Pain is the dominant factor in a patient's disorder • Range to the onset of pain, and slightly beyond Move to limitation of movement • Stiffness is sometimes more important than pain • Apply overpressure to assess end-feel and symptom response

PAIVM

Passive Accessory Intervertebral Movements - Perform 2 to 3 oscillations at each level both centrally and unilaterally - Vary the angles, force, and speed to determine the nature of the movement, behavior of the symptoms, and the range of movement - Always assess the upper portion of the thoracic spine when assessing the cervical spine

capsular pattern of C-spine

SB and rotation equally restricted -extension less limited -flexion remains full

soft tissue palpation

Sternocleidomastoids, scalenes, traps, masseter, temporalis, and down the borders of the scapulae

cyriax method: concepts of musculoskeletal dx

Three Concepts: 1. Active Movement-Passive Movement-Isometric Muscle Testing 2. What's the end-feel? 3. Does the joint have a capsular or non-capsular pattern? Once all of this information has been documented (both the positive and negative findings), the provisional diagnosis can be formulated

Agencies that have investigated PT preforming thrust manip include:

Veterans Hospital Association US department of Health and Human Services Virginia board of Medicine •Non-physical therapy agencies have investigated physical therapist competence in Thrust-Joint-Manipulation and have determined that Thrust-Joint-Manipulation is within the scope of practice for physical therapists -It is Believed that the Attempts to Limit Physical Therapists from Using Manipulation is Based on Economics and not Patient Safety -The evidence indicates that the health and welfare of the public is best served by physical therapists providing manipulation

soft dic herniation

a bulging, ruptured, or extruded nucleus pulposus -actual disc bulges, and there is some radiating sx

acute radiculopathy

a disorder of the cervical spinal nerve root, and most commonly is caused by a cervical disc herniation or other space occupying lesion (typically osteophytic encroachment associated with cervical spondylosis), resulting in nerve root inflammation, impingement, or both

selectivity

a test that differentiates one dysfunction from another

specificity

a test that finds a sign or symptom when the dysfunction is present

provocation

a test that provokes or intensifies symptoms

autonomic sx

blood perfusion, increased sweating or RR

where is the first disc located

c2-3

where do the most severe degenerative changes occur

c5-6, c6-7

A-A palpation uses

cervicogenic headache and enhances rotation

C2-3 palpation uses

cervicogenic headaches and hypomobility

contraindications to thrust joint manipulation

contraindication: fracture, osteoporosis, instability, RA (because of laxity and causes exacerbation), cancer -precautions: children (laxity)

transverse ligament testing

find the transverse processes of C1 and do a B P-A (push up) -if there is a tear, you would feel the movement

indication for SNAGs

for the more stiff/chronic pains, mechanical pain

when would manips be beneficial

if sx do not radiate past buttock, or if pain has been going on for less than two weeks

exercise application and prescription

in most cases a therapist is presented with a patient whose pathological process has occurred over an extended period of time resulting in pain and movement dysfunction -clear the tunnel and get freedom of mocement

severity

intensity + extent that they limit normal activity

heuristic

involves pattern recognition and the ability to lump useful findings together into coherent groups

hypothetical deductive

involves the development of a hypothesis during the examination, and the refuting or acceptance of that hypothesis that occurs during the examination process

commision on accreditation in PT education

is the sole accreditation agency recognized by the United States Department of Education and the Council for Higher Education Accreditation to accredit entry-level physical therapist and physical therapist assistant education programs

best way to tx migraines

meds

when does acute radiculopathy often occur? what are the most commonly affected segments?

most frequently reported to occur in the forth or fifth decade of life • It is generally agreed that involvement of the C6 and C7 nerve roots secondary to lesions of the C5-6 and C6-7 motion segments are most common

what is a tension point

points along the nervous system which do not move or have minimal movement in relation to surrounding structures -C6 (beginning of the cervical-thoracic junction going from lordotic to kyphotic) -T6 -L4 (area that moves the most... spine moves more than the nerve allows) -posterior knee/anterior elbow: in the popliteal fossa and cubital fossa... stretching of the nerve tissue (SLR)

thrust table risk

ppt 2 tables pyramid of evidence

what should you test if someone has a cervicogenic headache

restriction in flexion rotation flexion rotation test: lie supine -head off of bed, PT provides some traction, gets max flexion, then maintain flexion and rotate -while maximally flexed, rest head against torso and depress shoulders -we are locking out the entire cervical spine, if restricted to either side: higher chance of having cervicogenic headache --can start mobilizing in this area

sympathetic trunks

run anteriorly on the body of the cervical spine

dural test for the median nerve

sort of like this, but with head tilt away from active movement of the arm

treat the ____ not the ____

tx the tunnel, not the track -where the nerve comes from, mobilize proximally first then move distally

tx for posture

work on education -chin tuck/poke without pain -mobilization of thoracic spine

alar ligaments

—runs from the dens of C2 upward and lateral to the medial sides of the occipital condyles • Limits rotation of C1 on C2 and lateral flexion • Rotation right increases tension on the left ligament • Ligaments are relaxed in extension and tight in flexion

neurodynamic testing: ULTTs

• 1—Median • 2A—Median • 2B—Radial • 3—Ulnar

discogenic recovery

• 60—80% of acute symptoms will resolve in 4 to 6 weeks with rest and other conservative measures

howto perform mulligan technique

• A passive accessory joint mobilization is applied to the joint (parallel or perpendicular to the joint plane) and this accessory glide must be pain free • While the accessory glide is maintained, the patient is requested to move their effected extremity or spine toward the restricted direction to see if the restriction has been improved • The goal is to have the movement performed without the presence of the original complaint • Once the correct pain-free arthrokinematic adjustment glide is discovered, the previously limited and/or painful movement is repeated by the patient while the therapist continues to maintain the appropriate accessory glide • Further gains are expected with repetition during each treatment session especially when pain-free overpressure is applied

longitudinal traction- chin cradle

• Ability to apply more force than previous tractions • Be careful with the chin components (i.e. TMJ) • Vary the angles and palpate the interspinous spaces at the same time

cyriax method: concept 1

• Active ROM -Tests the willingness of the patient to move limb or trunk • Passive ROM -Tests the "inert structures" in and around a joint • Isometric Resisted Muscle Testing -Tests the "contractile structures" in and around a joint

hard disc herniation

• An intraforaminal spur from the uncovertebral or facet joint, or as a disc hardening, thickening, or calcification resulting in a medial ridge Hard disc herniations are commonly related to cervical spondylosis with or without radiculopathy

assessment modifiers

• Assessment modifiers are elements that are used in any of the three decision making models that are designed to improve the accuracy of the outcome - Examples of assessment modifiers include probabilistic statistics and clinical prediction rules • As an example—A patient with low back pain reports bladder retention, bilateral leg pain, and rapid neurological changes in their third visit, which points to cauda equina -This would be pattern recognition in the assessment and you would make the proper modification by referring immediately to the doctor

DTR

• Biceps (C5 or C6) • Brachioradialis (C5) • Triceps (C6)

cyriax method: concept 2

• Capsular versus Non-Capsular Patterns • Capsular pattern: a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilization • Non-capsular pattern: a limitation in a joint in any pattern other than a capsular one, and may indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion

coordination, strengthening, and endurance recommendations

• Clinicians should consider the use of coordination, strengthening, and endurance exercises to reduce neck pain and headache -Recommendation based on strong evidence

traction recommendations

• Clinicians should consider the use of mechanical intermittent cervical traction, combined with other interventions such as manual therapy and strengthening exercises, for reducing pain and disability in patients with neck and neck-related arm pain -Recommendation based on moderate evidence

upper quarter and nerve mob recommendations

• Clinicians should consider the use of upper quarter and nerve mobilization procedures to reduce pain and disability in patients with neck and arm pain -Recommendation based on moderate evidence

cervical manipulation/mob recommendations

• Clinicians should consider utilizing cervical manipulation and mobilization procedures, thrust and non-thrust, to reduce neck pain and headache • Combining cervical manipulation and mobilization with exercise is more effective for reducing neck pain, headache, and disability than manipulation and mobilization alone -Recommendation based on strong evidence

assess - maitland

• Continual assessment at all phases—after the initial examination, before and after treatments, etc. • Involves the patient's perspective and values, the clinician's expertise and reasoning, and the best available evidence -after: keep doing the things that make them feel better and avoid the things that makes them feel worse

similarities and contrasts

• Cyriax introduced the selective tissue tension tests which Maitland utilizes in looking at quality of movement and assessing passive overpressure • The consideration of joint mechanics in the mobilization approach utilizing concave-convex rules(Kaltenborn) is mimicked a littlebit by Mulligan (especially in spine movements) • Both Mulligan and McKenzie share a strong emphasis on self-management (HEP and self mobilizations) and repeated movements • A change in the pain response is used as an indication that the correct technique is being used which is believed by Maitland and Mulligan, and to a lesser degree McKenzie • A reproduction in the comparable sign or the client specific impairment measure are key elements in the examination process for both Maitland and Mulligan --The CSIM is very similar to Maitland's comparable sign—the physical activity or task that is easily reproducible in the clinic and directly incorporated into the MWM • Maitland and Kaltenbornhave specific grades for their mobilizations while Mulligan and McKenzie do have any grades --Gentle force is often all that is required to achieve an improvement in pain free function with mobilizations with movement and with McKenzie mobilizations --Mobilization with movements is unique in that it combines both active and passive elements • You can vary the direction of the mobilizations with Maitland and Mulligan • Continued assessment is primary in Maitland and Mulligan, somewhat in McKenzie, and very little in Cyriax

longitudinal traction- suboccipital release

• Eight fingers placed in the suboccipitalmuscles • Patient's head is resting with very little traction force being applied lumbrical grip, head is balanced on the fingertips (not touching palm) -deep sustained pressure (looking for a release) -arms should be down so forearms are on table -can use for a headache, upper cervical pain/tension

cyriax method: concept 3

• End Feel -Normal end feel equals a physiological end feel (you have reached physiological end range) -Abnormal end feel equals a pathological end feel (you are unable to reach physiological end range) Normal -Bone-on-Bone (Normal: elbow extension, knee extension) -Soft Tissue Approximation (Normal: elbow flexion, knee flexion) -Capsular Feel (Normal: shoulder external rotation, hip internal rotation) Abnormal -Springy Block (Always abnormal e.g., knee meniscal tear, hip labral tear) -Muscle Spasm (Always abnormal e.g., fracture) -Empty Feel (Always abnormal e.g., metastasis)

types of muscle tension headaches

• Episodic Type—periods of headache >30 minutes but <7 days • Chronic Type—>15 days with headache per month over 6 months

imaging

• Excessive use of imaging has been cited as a cause of escalating health care costs • Clinical practice Guidelines have recommended to refrain from ordering radiographs in the absence of red flags

stretching recommendation

• Flexibility exercises can be used for patients with neck symptoms • Examination and targeted flexibility exercises for the following muscles are suggested: anterior, middle, and posterior scalenes, upper trapezius, levator scapulae, pectoralis major and minor -Recommendation based on weak evidence

recovery of cervicogenic headache

• Headache disappears after one month after successful treatment or spontaneous remission of the underlying disorder

prodromal sx (in order of frequency)

• Homonymous visual disturbances • Unilateral sensory disturbances (tingling, numbness down one side of the body) • Unilateral motor disturbances • Aphasia

if the pain is still being provoked the PT has not.... - mulligan

• If the pain is still being provoked it indicates that the therapist has not: -Found the correct gliding direction (treatment plane) -Found the correct mobilization grade -Found the correct spinal segment -Maybe the technique is not indicated for this situation

mckenzie concept - MDT

• In 1981 Robin McKenzie launched the concept which he called Mechanical Diagnosis and Therapy (MDT) • This is a system that encompasses assessment (evaluation), diagnosis and treatment for the spine as well as the extremities

MRIs and discogenic problems

• MRI studies of assymptomatic individuals indicate that 40% of patients studied have disc abnormalities

which concepts are pt centered

• Maitland, Mulligan, and McKenzie

mechanisms of vertebrobasilar insufficiency

• Major trauma—MVA, fall, direct impact, contact sport injuries, etc. • Trivial trauma—sudden head movements, sporting activities, sustained rotation and/or extension,backing out of driveway • Spontaneous—non-recent trauma, past VBI, driving in car, pregnancy, standing up briskly after a nap

mobilization with movement

• Mobilization with movement is defined as the application of a specific vector of force to a joint which is sustained while the patient performs a previously impaired task • The key to successful use of MWM is the skillful and efficient application of the mobilization force so as to achieve immediate and long lasting relief of the patient's impairment measure • The CSIM (client specific impaired movement) needs to reflect the patient's main concern

LBP guidelines

• New Zealand Guidelines Group (NZGG, '98)—Manual loading of the spine using short or long leverage methods is safe and effective in the first 4-6 weeks of acute low back symptoms.(Strength of Evidence = Moderate) • Royal College of General Practitioners (RCGP, '96 & '01)—Within the first six weeks of onset of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared. (Strength of Evidence = 3 stars) • Strong evidence supporting thrust and/or non-thrust manipulation plus exercise to improve short- and long-term outcomes of care for patients with neck pain disorders

What is Orthopaedic Physical Therapy?

• Orthopedic physical therapy encompasses the examination and treatment (intervention) of musculoskeletal disorders, prevention of disability related to dysfunction of the musculoskeletal system, and enhancement of the performance of the musculoskeletal system. • Due to the prevalence of musculoskeletal problems among people of all age groups and occupations, orthopedic physical therapy is practiced in a variety of settings including out-patient clinics, in-patient departments at acute or chronic care facilities, home health care, sports and fitness centers, universities, and industrial sites.

cervicogenic headaches

• Pain is localized to the neck and occipital region—may project to the forehead, orbital region, temples, or ears • Pain is precipitated or aggravated by special neck movements or sustained postures • There will be: -Resistance to, or limitation of passive neck movements -Changes in neck contour, texture, tone or response to active and passive stretching and contraction) -Abnormal tenderness of neck muscles

kind

• Pain-stiff, stiff-pain, stiff, weakness, instability, incoordination

signs of craniocervical damage and instability

• Paraesthesia of the lips and tongue (connections of the hypoglossal nerve—ventral ramus of C 2 ) • Signs of vertebral artery compromise • Cord signs • Increase in motion or empty end feel on test movements • Reproduction of symptoms of instability • Lateral nystagmus

SB manip

• Patient is supine with head off the table • Thrusting knuckle is placed on the targeted articular pillar • Side bend the head toward you until you feel movement at the targeted level under the thrusting knuckle • Rotate away and extend until you find the end of range • Fine tune the movements until it feels firm • Apply a high velocity, low amplitude movement into side bending toward you - The movement is directed laterally and slightly downward for C7, lower cervical spine -pt in sitting, PT has leg on bed, pt's arm goes on leg to provide slack on the upper trap -extend head to find C7, block C7 from going posterior -SB down, rotate up and thrust down use the thrusting knuckle on the lateral boerder: just behind the SCM -second MCP goes behind lateral border to be a stabilizer -laterally flex to the point where you feel engagement or complete non-movement (going past a segment) -hold position, rot away until you feel movement, extend... should be locked -chin cradle (index finger and middle finger split chin) -deep breath in, out, take up slack

migraine without aura is characterized by

• Periodic headache lasting 4—72 hours • Rarely >6 attacks per month • At least two of the following characteristics: Unilateral Throbbing/pulsating/bursting Severe (interferes with ADLs) Increases with light physical activity • At least one of the following symptoms: Anorexia, nausea, and/or vomiting Photophobia and/or phonophobia

proposed mechanisms for MWM

• Restoration of a positional fault or minor bony incongruity— allows normal movement of the joint and reinforces a normal movement pattern in the patient • A non-painful manual contact and forces applied with a MWM are likely to stimulate A-beta fibers • This theory aligns with how TENS units work in depressing pain in patients • In summary, the underlying mechanisms of action for MWMs are likely multifaceted involving local (joint and bone) and central (behavioral, neurophysiological) mechanisms and these are plausibly dependent on many factors (patient's presenting condition, how the technique is applied, etc.)

cervical myotomes

• Shoulder Shrugs (C2, C3, C4 and CN XI) • Shoulder Abduction (C5) • Shoulder Adduction (C7) • Medial and Lateral Rotation (C5 and C6) • Elbow Flexion (C5 or C6) • Elbow Extension (C7) • Wrist Extension (C6) • Wrist Flexion (C7) • Wrist Ulnar Deviation (C8) • Thumb Adduction/Abduction/Extension (C8) • Abduction/Adduction of the hand intrinsics(T1)

centralization recommendations

• Specific repeated movements or procedures to promote centralization are not more beneficial in reducing disability when compared to other forms of interventions -Recommendation based on weak evidence

serious complications of thrust manip

• Ten episodes of cauda equinasyndrome following lumbar manipulation reported (none from physical therapists) • Estimated risk: < 1 per 10 million manipulations • 177 patients (1925-1997) who experienced adverse events with manipulation • 39.6 years (4 months - 87 years), even distribution between males and females (80 males, 90 females) • Primary diagnoses included arterial dissection/spasm and brain stem lesions • 32 cases (18%) resulted in death • <2% adverse events were caused by physical therapists (no deaths were caused by PTs) • Impossible to determine the precise risk Not all events published in peer-reviewed literature No accepted standard for reporting these injuries • Risk of serious complications approximately 6 per 10 million* (Hurwitz, Spine, 1996) • Risk of death estimated at 3 in 10 million* manipulations (Hurwitz, Spine, 1996)

mulligan

• The Mulligan Concept focuses on correcting altered arthrokinematics by mobilizing joints during active movements • Correct the positional fault of the joint and allow it to move in a pain free manner

sidelying slump

• The sidelying slump is another variation of the slump test and it is meant to assess the femoral nerve • The patient lies on their uninvolved side and fully flexes the neck and pulls into the fetal position while manually flexing the uninvolved extremity • The examiner takes the involved extremity and extends the knee and slightly abducts the leg • The leg is then extended at the hip in an effort to tension the femoral nerve

ANS

• The sympathetic trunks of the autonomic nervous system lie just anterior to the ever moving costo-transverse joints (sympathetic trunks of the thoracic spine) • The anterior view shows that lateral flexion will tighten the sympathetic chain, and the side view reveals that flexion is likely to stretch the thoracic and lumbar chains while cervical extension will stretch the chains

longitudinal traction- towel

• Therapist leans back gently • The angles of flexion, extension, and lateral flexion can be varied • Good home exercise for care giver or spouse to perform fold towel so it is thin, bring towel over the occiput and ears, arms into thorax, PT in stride step, lean back, drop bum -can laterally side bend

summary of evidence

• There is greater evidence for spinal manipulation than most other physical therapy interventions There is strong evidence for thrust manipulation for the subgroup of patients with acute low back pain Strong evidence for mobilization /manipulation combined with exercise for subgroup of patients with neck pain • Clinical prediction rules (CPR) have been developed by physical therapists to help guide clinical decision making in the use of Thrust-Joint-Manipulation • It is recommended that clinical prediction rules be integrated with an impairment-based approach • Billions of dollars are spent each year in an effort to treat musculoskeletal conditions. Exercise combined with manipulation provided by physical therapists may be part of the solution • Chiropractors feel threatened and are fighting back with regulatory and legislative strategies

what can degenerative changes lead to

• These changes lead to loss of shock absorbing capacity resulting in abnormal force transmission and increased load to the facets • Therefore, cervical facet degenerative changes commonly follow intervertebral disc degeneration • The combination of decreased intervertebral disc space and facet joint degeneration with hypertrophy causes narrowing of the intervertebral foramina with potential compression of the exiting nerves and associated radicular symptoms

sympathetic slump

• This stretch is a variant of the slump and is meant to apply a stronger stretch on the thoracic spine and to provide a strong assessment on the sympathetic trunks located in the thoracic spine • The test is performed on a treatment plinth in long sitting position with both legs bent approximately 60 degrees at the hips and knees • The therapist stands on the side opposite the symptomatic side -pt sits with hands behind them and palms up so PT can see if their is a sympathetic stage • The subject places both hands behind the back to assist in getting them out of the way and to prevent them from bearing weight on the arms during the testing • The subject is asked regarding their current symptom level then asked to assume a slouch sitting posture • The subject is asked again concerning symptom level changes then neck flexion is added • Trunk side flexion away from the involved side followed by thoracic rotation away from the involved side • Extend the knee on the involved side • Add cervical protraction followed by cervical extension followed by cervical lateral flexion away from the involved side • Look for autonomic/sympathetic signs like changes in blood flow in the hands -Testing the sympathetic trunk of the autonomic nervous system

distraction test

• This test is one of the best diagnostic scores of the tests of cervical radiculopathy, according to Cook

thoracic manipulation/mob recommendations

• Thoracic spine thrust manipulation can be used for patients with primary complaints of neck pain • Thoracic spine thrust manipulation can also be used for reducing pain and disability in patients with neck and neck-related arm pain -Recommendation based on weak evidence

passive lower cervical extension quadrant (combo)

• Three components—extension, ipsilateral side bend, and ipsilateral rotation • Place the heel of your other hand on the contralateral zygomatic arch with your thumb resting on the bridge of the nose - Passively move the lower cervical spine into a combination of extension, rotation, and side bending to the same side towards your chest—you can perform this in one movement or broken into the separate components -look for VBI sx -uncomfortable, can often reproduce sx

pt education/counseling recommendations

• To improve the recovery in patients with whiplash-associated disorder, clinicians should: Educate the patient that early return to normal, non-provocative pre-accident activities is important Provide reassurance to the patient that good prognosis and full recovery commonly occurs -Recommendation based on strong evidence

longitudinal manip AO-C1-2

• Traction manipulation of the Occipital-Atlanto-Axial joints • Patient is supine near the edge of the table and head off the table • Therapist employs the chin cradle grip and the head is midway between flexion and extension • Rotate the patient's head away to expose the mastoid process • The thrusting knuckle of your other hand hooks the mastoid process • Return the head to the neutral position with the forearm resting on the patient's chest • Apply a high velocity low amplitude thrust cranially -thrusting knuckle is on lateral border (first knuckle of first finger) -SB towards, rotate away, extend -thrusting knuckle moves with movement -find where they lock out -thrust in same direction: SB with other hand -for mechanical pain, neck pain that is not radiating that has been around for less than 2 weeks distraction manip: move pt to one side of table, place thrusting knuckle on base of occiput and turn feet towards eyes, forearm on shoulder -breath in, out, take up slack, distract a-o joint -thrusting knuckle grabs on to the occiput of one side -point feel in opposite direction of elbow -bias one side, go through the range, deep breath in, take up all the slack, pull out towards top of head -head stays neutral

maitland treatment

• Treatment is derived from the assessment and clinical reasoning process • Passive movements can be a useful options even in problems that may have other more dominant mechanisms explaining the reason for the problem -Maitland is a strong advocate of gentle passive movements -in general recommends using the most gentle treatment needed to achieve success -known for mobilization, especially gradual mobilization --don't go past point of pain, just gently move in the direction of pain -pain 1-2, stiffness 3-4

nature

• Type—aching, throbbing, burning, stabbing, sharp, dull, deep, superficial, etc. • Radiating, referred, localized, etc. • Tissue and Injury—sprain, degenerative joint disease, fracture, osteoporosis, neural in nature • Degree of injury—1 st —3 rd degree, mild to severe, etc.

distribution of tension and movement

• When the body is moved, the consequences for the nervous system will be spread over a greater distance than for non-neural structures • For example, dorsiflexion of the ankle will mechanically influence the nervous system in the lumbar spine and perhaps further • The spread of tension and movement in terms of distance and amplitude is not really known and will presumably be dependent on a number of factors, of which most important is the position of the rest of the body

what does mckenzie believe

• that the majority of low back pain is "mechanical" in origin, meaning that an applied force (such as an active movement) causes the pain • A basic philosophy of the McKenzie theory is that the reverse force can probably abolish the pain and restore function- if there is pain with flexion, bend in extension • The McKenzie Method is grounded in finding a cause and effect relationship between the positions a patient usually assumes while sitting, standing or moving, and the location of their pain as a result of those positions and/or activities

average dural movement with cervical flexion/extension

•C5 3.0mm •C8 9.0mm •T1 13.0mm •T5 7.0mm •T102.0mm

what does the APTA show

•Manipulation is within the scope of physical therapy practice. •The entire continuum of manipulation procedures (thrust and non-thrust) are taught in professional physical therapist education.

mckenzie summary

•The McKenzie Method is most commonly used in diagnosis and treatment of low back pain and neck pain, but it is also used in peripheral joint complaints as well